REPUBLIC OF THE PHILIPPINES }

CAGAYAN DE ORO CITY } S.S.

AFFIDAVIT OF LOSS

I, _________________________, of legal age, Filipino, married, and a resident of

__________________________, after having been sworn to in accordance with law, hereby depose
and say that:

1. I am the father of the minor child _____________________, a Grade 10 student of

______________________________;

2. She is a holder of a Filipino book issued by the above-mentioned school for

the School Year 2019-2020;

3. As such, she is obligated to return the said book at the end of the school year;

4. However, sometime in July 2019, she misplaced the book in school;

5. Diligent efforts were exerted to find the said book, but the same were
irretrievably lost;

6. I am executing this Affidavit of Loss to attest to the veracity of my statement

and for whatever purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affix my signature this ___________________ at

________________________, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ in ____________________,

affiant exhibiting to me his Driver’s License with ID No. ____________________ issued by the
Land Transportation Office as competent proof of identification.

Doc No.  _____                                                             

Page No. ______                                           
Book No. ______                                              
Series of 2020.